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92 www.jkscience.org Vol. 16 No.2, April-June 2014

CASE REPORT

From the Department of Surgery, Urology* & Pathology**, ASCOMS and Hospital, Sidhra , Jammu.Correspondence to : Dr Sarbjit Singh, Associate Professor, Department of Surgery, ASCOMS and Hospital, Sidhra , Jammu.

Anal Stenosis Following SclerotherapyManaged by Anoplasty

Sarabjit Singh, I Shah*, Anil Sharma, Yawar Watali, Ozma Masoodi**, Syed Rayees

Anal stenosis is a rare but serious disabling conditionfollowing ano rectal surgery, anal trauma, carcinoma, postradiotherapy and Crohn's disease. (1,2) 90% of the analstenosis is causes by overzealous haemorrhoid surgery.Stricture following sclerotherapy is also mentioned in theliterature. (3) This narrowing may result from a trueanatomical stricture or a muscular stricture .Which leadsto a functional stenosis. Diagnosis is not difficult as thepatients usually presents with difficult or painful bowelmovements. (4-6) On the basis of severity, stricturesare divided into mild, moderate and severe anal stenosis.Case Report

We hereby present 2 cases both middle aged femaleswith no comorbid diseases. Both had severe anal stenosiscaused by sclerotherapy for the treatment ofhaemorrhoids, by an unqualified medical practitioner.These injections were given all around the anus. Patientrevealed that 3-4 injections were given , which led todiaphragmatic annular type tight anal stricture (Fig1) withfunctional disability. Patient had undergone injectiontherapy a year earlier and from last 8 months weresuffering from difficult painful bowel movements .Patientspassed thin ribbon like stool after lot of exertion. On

AbstractAnal stenosis is a severe anal stenosis can result from overzealous haemorrhoidectomy. It is a seriousdisabling disease. Patient presents with difficult and painful bowel movements. We present with a cases ofdisabling anal stenosis following sclerotherapy of haemorrhoids leading to severe anal stenosis withdiaphragmatic ring like annular stenosis. A formal Y-V anoplasty was performed which relieved thepatients of their symptoms leading to satisfactory bowel movements.

Key WordsSevere anal stenosis, Sclerotherapy, Overzealous haemorrhoidectomy, anoplasty

Introductionexamination the stenotic anus did not allow insertion oftip of little finger (Fig 1). Only a tip of artery forceps(3mm) could only be passed after the routineinvestigations patients were taken up for surgery and Y-V anoplasty 2,1,4,5 was performed at the right lateralposition with lateral internal sphincterotomy. Flap wassutures using an absorbable vicryl suture taking specialcare of the tip of the flap as it is known to undergonecrosis. (2) A good mobilisation of the flap reduces therisk of necrosis. A tube drain was kept with gauze packingwhich was removed after 36 hours. Recovery wasuneventful, patients were discharged on stool softenerwith advice to follow up in OPD for periodical analdilatations . After 6 months patients are doing well onfollow-up (Fig 3) with relief of symptoms and completebowel satisfaction.(4)Discussion

Anal stenosis, although rare , is one of the most fearedand disabling complication of ano rectal surgery. It hasbeen known that haemorrhoidectomy is the most frequentcause but stenosis ,may be consequence of other causes.Several operative and non operative techniques to treathaemorrhoids have been described, Milligan Morgan open

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haemorroidectomy most commonly performed, SRMstapled rectal mucosectomy, Parks submucosal andinjection therapy are operative and non operativetechniques mentioned . Our patient had also undergoneinjection therapy. physical examination confirms thediagnosis . Visual examination of anal canal and peri analskin along with digital rectal examination usually sufficeto establish the presence of anal stenosis .On planning atreatment for anal stenosis it is very important to knowthe severity of the disease . Milson and Mazier 6distinguished anal stenosis as mild, moderate and severeon the basis of examination of tight anal canal bylubricated index finger or a Hill Ferguson's Retractor.Severe stenosis is labelled when little finger cannot beinserted as in our case only tip of the artery forcep (3mm)could be passed (Fig 2) .Further more stenosis may bediaphragmatic , ring or annular type. In our case it was

Fig. 1 Skin-colored, 15×4×3 mm Sized Solitary, ProtrudedPapule on the Palmar Aspect of Hand Showing Collarette ofSlightly Raised Skin

diaphragmatic type stricture. Best treatment is preventionat the time of surgery. Mild to moderate strictures areusually managed by non operative techniques but severestenosis is managed by formal anoplasty to treat the lossof anal tissue. Various type of flaps have been describedwhich are rotational or advancement flaps. We have doneY-V advancement flap using vicryl as suture material .Agood mobilisaion and suturing without tension of the flapprevents the flap tip necrosis . Both the cases recovereduneventfully and were discharged on stool softeners withadvice for periodic dilatations during follow-up. Recoverwas good as discribed by Casadesus et al. Patients wererelieved of the symptoms . At 6 months follow up theresults were excellent (Fig 3).

Fig. 3 Biopsy Showing Dermis with Bands of Thick Collagenalong with Perivascular and Periappendageal ChronicInflammation (H &E X 100)

Fig.2 Biopsy Showing Marked Hyperkeratosis, Acanthosisand Papillomatosis of Epidermis (H& E X200)

1. Angelchik PD, Harms BA, Starling JR. Repair of analstricture and mucosal ectropion with Y-V or pedicle flapanoplasty. Am J Surg 1993; 166: 55-592.

2. Brisinda G, Vanella S, Cadeddu F, Marniga G, Mazzeo P,Brandara F, Maria G. Surgical treatment of anal stenosis.World J Gastroenterol 2009; 15(16): 1921-19283.

3. Casadesus D, Villasana LE, Diaz H, Chavez M, SanchezIM,Martinez PP, Diaz A. Treatment of anal stenosis: a 5-year review. ANZ J Surg 2007; 77: 557-5594.

4. Filingeri V, Gravante G, Cassisa D. Radiofrequency Y-Vanoplasty in the treatment of anal stenosis. Eur Rev MedPharmacol Sci 2006; 10: 263-267

5. Gingold BS, Arvanitis M. Y-V anoplasty for treatment ofanal stricture. Surg Gynecol Obstet 1986; 162: 241-242

6. Milsom JW, Mazier WP. Classification and management ofpostsurgical anal stenosis. Surg Gynecol Obstet 1986; 163:60-64

References